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STATE OF CALIFORNIA • a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION. FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY I NEW PERMIT ❑ 0 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ e TEMPORARY TANK CLOSURE ❑ B TANK REMOVED _ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I ,-T T-9 /bl"'2- I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNERS TANK I.D.0 B. MANUFACTURED BY: C. DATE INSTALLED(MOIOAYNEAR) 1 I l D. TANK CAPACITY IN GALLONS: S II.TANK CO MS IFA-1ISMARKED.COMPLETE ITEM C. A. MOTOR VEHICLE FUEL ❑ A OIL g, O is REGULAR 0 DIESEL UNLEADED ❑ e AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ iE PREMIUM A GASAHOL ❑ 7 METHANOL ❑ 7 CHEMICAL PRODUCT ❑ ❑95 UNKNOWN ❑ 2 WASTE UNLEADED ❑ 5 JETFUEL 2 LEADED ❑ gp OTHER (DESCRIBE IN REM p, BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OFSUBSTANCE STORED C. M: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A BAND C.AND ALLTHATAPPUES IN BOX C:] y"" A. TYPE OF UBLE WALL ❑ S SINGLE WALL WITH EXTERIOR LINER N ❑ 95 UNKNOWN L.. SYSTEM 2 SINGLE WALL ❑ a SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 0 FIBERGLASS ❑ A STEELCLAO W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ S CONCRETE ❑ B POLYVINYL CHLORIDE ❑ 7 UMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER UNEO ❑ 2 ALKYD LINING ❑ 0 E LINING ❑ A PHENOLIC LINING C.I LINING ❑ 5 GLASS LINING ❑ e UNLINED 5 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ INYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE =95 UNIWOWN ❑ 99 OTHER IV.PIPING INFORMATIW CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE U SUCTION A U 2 PRESSURE A U 7 GRAVITY A U 99 OTHER B. CONSTRUCTION rU 1 SINGLE WALL A U 2 DOUBLE WALL A U S LINED TRENCH A 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 2 POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 ST W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHCOIC PROTECTION U 95 UNKNOWN A U 99 OTHER O. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TE ING J MIN S UL ONRORING gg OTHER / V.TANK LEAK DETECTION pppUUUUUUYYYYTT ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ a OMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING N ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE (�9/5 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/OAY/YR) 2.ESTIMATED OUANTITY OF 0.WAS TANK FILLED WITH O- I,�— 9I SUBSTANCE REMAINING GALLONS I INERTMATERIAL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME IPMNTEDA glc AiuRM GATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY a JURISOICTION it FACILITY# TANK 9 STATE LD. ® I�T1 U �r d0 U rD LW PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT E%PIRgTION DATE FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. F0R981iB.R4